Provider Demographics
NPI:1063124451
Name:LISA BLAKE THERAPY
Entity type:Organization
Organization Name:LISA BLAKE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-695-5057
Mailing Address - Street 1:1314 24TH ST
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-2902
Mailing Address - Country:US
Mailing Address - Phone:801-695-5057
Mailing Address - Fax:
Practice Address - Street 1:4933 S 1500 W STE 200
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:UT
Practice Address - Zip Code:84405-7738
Practice Address - Country:US
Practice Address - Phone:801-695-5057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)